Vaccine Recommendations for Travelers with Altered Immunocompetence, Including HIV

May 22, 2001

Please see the Destinations section for recommendations for specific countries.

Killed or inactivated vaccines do not represent a danger to immunocompromised travelers and generally should be administered as recommended for healthy travelers. However, the immune response to these vaccines might be suboptimal.

Virus replication after administration of live, attenuated virus vaccines can be enhanced and prolonged in travelers with immunodeficiency diseases and in those with a suppressed capacity for immune response, as occurs with HIV disease; leukemia; lymphoma; generalized malignancy; or therapy with corticosteroids, alkylating agents, antimetabolites, or radiation. Severe complications have been reported following vaccination with live, attenuated virus vaccines (for example, measles and polio) and with live bacterial vaccines (for example, Bacille Calmette-Guerin [BCG]) in patients with HIV disease, leukemia, and lymphoma or other people with suppressed capacity for immune response. In general, travelers with such conditions should not be given live organism vaccines.

Evidence based on case reports has linked measles vaccine virus infection to subsequent death in six severely immunosuppressed persons. For this reason, travelers who are severely immunosuppressed for any reason should not be given measles, mumps, and rubella (MMR) combined vaccine. Healthy, susceptible close contacts of severely immunosuppressed travelers may be vaccinated. MMR and other measles-containing vaccines are not recommended for HIV-infected travelers with evidence of severe immunosuppression (for example, travelers with a very low CD+4 T-lymphocyte count), primarily because of the report of a case of measles pneumonitis in a measles vaccinee who had an advanced case of AIDS. Refer to the 1998 Advisory Committee on Immunization Practices (ACIP) statement on MMR (PDF) for additional details on vaccination of travelers with symptomatic HIV infection.

Measles disease can be severe in people with HIV infection. MMR vaccine is recommended for all asymptomatic HIV-infected travelers and should be considered for symptomatic travelers who are not severely immunosuppressed. Asymptomatic infants, children, and adolescents do not need to be evaluated and tested for HIV infection before MMR or other measles-containing vaccines are administered. A theoretical risk of an increase (probably transient) in HIV viral load following MMR vaccination exists because such an effect has been observed with other vaccines. The clinical significance of such an increase is not known.

In general, travelers receiving large daily doses of corticosteroids (>2 milligrams per kilogram [mg/kg] per day or >20 mg per day of prednisone) for 14 days or more should not receive MMR vaccine because of concern about vaccine safety. MMR and its component vaccines should be avoided for at least one month after cessation of high-dose therapy. Travelers receiving low-dose or short-course (fewer than 14 days) therapy; alternate-day treatment; maintenance physiologic doses; or topical, aerosol, intra-articular, bursal, or tendon injections may be vaccinated. Although travelers receiving high doses of systemic corticosteroids daily or on alternate days during an interval of less than 14 days generally can receive MMR or its component vaccines immediately after cessation of treatment, some experts prefer waiting until 2 weeks after completion of therapy.

Travelers receiving cancer chemotherapy or radiation who have not received chemotherapy for at least 3 months may receive MMR or its component vaccines.

Travelers with leukemia in remission whose chemotherapy has been terminated for at least 3 months and transplant recipients who are beyond the period of immunosuppression may receive live virus vaccines. Most experts agree that steroid therapy usually does not contraindicate administration of live virus vaccine when it is short term; low to moderate dose (less than 2 weeks); long-term, alternate-day treatment with short-acting steroids; maintenance physiologic doses (replacement therapy); or administered topically (that is, to the skin or eyes) by aerosol or by intra-articular, bursal, or tendon injection.

Infants and children infected with HIV should receive, on schedule, all the routinely recommended inactivated vaccines (that is, acellular pertussis [DTaP], Haemophilus influenzae type B [Hib], and hepatitis B vaccines) whether or not they are symptomatic. Inactivated poliovirus vaccine (IPV) is the polio vaccine of choice for HIV-infected asymptomatic and symptomatic travelers and their household members and other close contacts. Pneumococcal vaccine is recommended for anyone six months of age or older with HIV infection. Because influenza can result in serious illness and complications, vaccination against influenza is a prudent precaution in HIV-infected travelers. Varicella vaccine may be considered for asymptomatic HIV-infected travelers with CD4+ percentages >25% (CDC Class 1; that is, no evidence of suppression).

Because oral poliovirus vaccine (OPV) is no longer available, IPV should be used to immunize HIV-infected travelers and their household contacts.

Safety of Vaccines for HIV-Infected People

Scientists have reviewed the safety and efficacy of vaccines (such as those for measles, yellow fever, influenza, or pneumococcal pneumonia) in people with HIV infection or AIDS. No increased incidence of adverse reactions to inactivated vaccines has been noted in these people. However, administration of live organism vaccines can carry increased risks of adverse reactions (see especially the sections on measles and yellow fever). In addition, the likelihood of successful immune response is reduced in some HIV-infected people (depending on the degree of immunodeficiency). On the other hand, because of their immunodeficiency, many HIV-infected people are at increased risk for complications of vaccine-preventable diseases. Thus, the risk-benefit balance usually favors administration of vaccines to HIV-infected people, especially inactivated vaccines. Administration of vaccines should be backed up by behaviors to prevent infections (for example, avoiding mosquito bites in yellow fever areas and avoiding exposure to people with measles or chickenpox).

To learn more about vaccine recommendations, see the Vaccinations section.

For more information about AIDS and other diseases mentioned on this page, see the Diseases section.

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